Why Is My Ankle Clicking

Introduction

Have you started to notice a clicking sensation in your ankle while walking or going up and down stairs?

Ankle ‘clicking’ is not uncommon and most of the time is nothing to worry about and is not associated with pain.  In fact, if it is not painful it is rarely anything to worry about. The noise is gas bubbles in the joint fluid ‘collapsing’ and releasing energy. However, if the clicking is associated with pain or weakness and you feel like you may ‘twist’ or ‘roll’ your ankle (or if you are ‘twisting’ your ankle), then we would advise you get it checked out by one of our expert physiotherapists.

Our physios will be able to assess you for other causes of the ‘clicking’ that may require specific management. The most common reasons for ‘ankle clicking’ are:

1. Ankle joint osteoarthritis – this is ‘wear and tear’ of the ankle joint itself.
2. Loose body in the joint – this could be a small bit of bone floating due to previous injury such as an ankle sprain.
3. Ankle ‘synovitis’ – this is chronic inflammation of the joint lining, known as the synovium. This can be due to a previous ligament sprain or a rheumatological condition such as gout or rheumatoid arthritis.
4. Hypermobility conditions – hypermobile patients often have lax joints due to ‘stretchy’ ligaments. This can cause ‘laxity’ or excessive movement in the joint which can lead to ‘clicking’.
5. Peroneal tendon subluxation – In this article, we will focus on ankle clicking caused by peroneal subluxation.  We will discuss the causes of peroneal subluxation, its symptoms, how to get a diagnosis and potential treatment options.

Understanding Ankle Clicking

As we mentioned earlier most ankle clicking is harmless and not indicative of an underlying issue or injury. However, at Complete Physio we feel it is important to differentiate between occasional painless clicking, which might be a result of gas bubbles releasing in the joint, and regular, repetitive, or painful clicking that may be linked to an underlying injury or condition.

What is Peroneal Subluxation?

Peroneal subluxation, also known as peroneal tendon subluxation or dislocation, is a condition in which the peroneal tendons (located behind the outer ankle bone – see below image) become displaced from their normal position. This is often occurring with specific ankle movements i.e. dorsiflexion (pulling foot up) and eversion (turning foot out). The most common cause of peroneal subluxation is due to a previous injury or laxity to a small anatomical structure that keeps the tendon behind the bone, this is known as the ‘superior retinaculum’. If this retinaculum is injured or lax, the tendons move anteriorly over the fibula bone i.e. the bone on the outside of the ankle. This causes the ‘clicking’, when it moves anteriorly and when it relocates back behind the bone.

Repetitive displacement of the tendons can cause thickening of the tendon (known as ‘tendinopathy’), inflammation of the tendon and its outer sheath (known as ‘tenosynovitis’) and/or a tear in the tendon.

These tendons play a crucial role in stabilising the ankle joint during movement and so this condition can lead to ‘weak’ ankles and a tendency to ankle sprains.

What Causes Peroneal Subluxation?

Several factors can contribute to peroneal subluxation:

1. Ankle Trauma: This is the most common reason for peroneal subluxation. A previous ankle injury such as a ligament sprain or tear or a broken bone, can weaken the supporting structures, making it easier for the tendons to slip out of place. The superficial retinaculum can be damaged/torn when the ankle is injured. Because this structure acts as a strap, keeping the peroneal tendons in place, once damaged the peroneal tendons can slip out of place (also known as ‘subluxing’) causing a painful clicking.

2. Anatomical Variations: Individuals with naturally shallow groove in the bone (fibula) that house the peroneal tendons are more prone to peroneal ‘subluxation’.

3. Overuse or Repetitive Motion: Activities that involve repeated ankle motion can strain the tendons and cause micro-trauma and weakness to the retinaculum leading to displacement and subluxation.

4. Muscular Imbalances: Weakness in certain muscles and tightness in others can alter the alignment of the tendons.

5. Hypermobility: This condition affects all soft tissues including the retinaculum which means it is less effective at maintaining the stability and location of the tendons behind the bone.

What are the Symptoms of Peroneal Subluxation?

Symptoms of peroneal subluxation include:

• Clicking Sensation: Audible clicking or snapping around the outer aspect of the ankle joint during movement.
• Pain and Discomfort: Persistent pain on the outer side of the ankle, often exacerbated by physical activity. Pain and clicking often occurs at the same time rather than independently to one another.
• Swelling and Inflammation: Visible swelling and redness may also be seen behind the bone on the outer aspect of the ankle.

How do we diagnose peroneal subluxation?

Peroneal subluxation can be diagnosed without any scans by an experienced physiotherapist. At Complete Physio, all our physiotherapists are highly specialised clinicians with extensive experience of ankle injuries and specifically causes of ankle clicking.

Your physiotherapist will ask you specific questions and carry a full clinical examination including specific tests to diagnose ‘peroneal subluxation. They will also assess why it has happened and what the underlying cause is. On some occasions a diagnostic ultrasound scan may be required to gain further information.

Diagnostic ultrasound is an excellent tool used by physiotherapists for assessing the ankle joint. If you feel you may need an ultrasound scan, you must request an appointment with one of our clinical specialist physiotherapists. Our team of clinical specialists are dual trained as physiotherapists and musculoskeletal sonographers.  This combination of expertise allows for a quick and accurate diagnosis.  Allowing you to start the most effective treatment possible.

The Role of Diagnostic Ultrasound

Diagnostic ultrasound visualises all the main structures around the ankle joint including the peroneal tendons, superior retinaculum, and ligaments. Ultrasound is superior to MRI scan for diagnosing peroneal subluxation. This imaging technique uses high-frequency sound waves to create real-time images of many internal structures. By capturing dynamic images of tendons, ligaments, and joints diagnostic ultrasound provides clinicians with a valuable in-depth understanding of what is going on under the skin.

The ultrasound scan will be able to answer important questions about your ankle issue and clicking, such as:

1. Have you torn the superior retinaculum or is it lax?
2. Do your tendons migrate over the bone on the outside of the ankle i.e. the fibula bone and how easily – is it infrequent or constant? Does the tendon relocate to the original position behind the bone, if so, how easily? Generally, the easier it ‘subluxes’ i.e. moves from behind the bone to in front of the bone, the more difficult these conditions are to treat with non-surgical options such as physiotherapy.

3. Have you torn your peroneal tendon, or do you have a tendinopathy or tenosynovitis?

Benefits of Diagnostic Ultrasound for Peroneal Subluxation

1. Real-time Assessment: Unlike other imaging methods such as X-ray or MRI, diagnostic ultrasound offers real-time imaging i.e. it can be carried out at your physiotherapy appointment there and then in the clinic.
2. Dynamic assessment: Peroneal sublocation often occurs with certain ankle movements, normally dorsiflexion (pulling foot up) and eversion (turning foot out). Ultrasound allows us to visualise the structures whilst you move your ankle i.e. a dynamic assessment.
3. Non-invasive: Once again, unlike X-Ray, diagnostic ultrasound is non-invasive, which means it emits no radiation. This makes it a safer and more patient-friendly option.
4. Accuracy: The detailed images produced by ultrasound provide clinicians with a high level of accuracy when diagnosing peroneal subluxation. This aids in determining the severity of the condition and planning suitable treatment.
5. Guidance for Treatment: Once diagnosed, the precise information obtained from diagnostic ultrasound can help guide a tailored treatment plan. This often includes physiotherapy and rehabilitation, orthotics (inner soles for your shoes), or in some cases, surgical referral.
6. Monitoring Progress: Diagnostic ultrasound can be regularly used to assess progress, ensuring that the tendons are healing properly, and that treatment is being effective

At Complete we have a team of clinical specialists who are dual trained as physiotherapists and musculoskeletal sonographers.  This combination of expertise allows for a quick and accurate diagnosis.  Allowing you to start the most effective treatment possible.

What are the Treatment Options for Peroneal Subluxation?

If you suspect peroneal subluxation as the cause of your ankle clicking, consulting a clinical specialist for an accurate diagnosis is essential. Once an accurate diagnosis has been made the right treatment can be selected.

Treatment options may include:

1. RICE: Rest, Ice, Compression, and Elevation , combined with anti-inflammatory medications, can help manage pain and inflammation.
2. Physiotherapy:  Stability (balance) and strengthening exercises as well as ankle stretches can help address any muscular imbalances that may be present, perpetuating the condition.
3. Shockwave Therapy: This treatment can be used to stimulate healing within tendons and, in some cases, can be used to treat the peroneal tendons. This is mainly reserved for tendinopathy cases and with infrequent ‘subluxation’.
4. Bracing: Ankle braces can provide additional support to the tendons, allowing them to calm down as well as prevent further subluxation.
5. Surgery: In severe cases, where all conservative methods fail, surgical procedures can be used to stabilise the peroneal tendons in their correct position.

Conclusion

Most ankle clicking is nothing to worry about. Peroneal subluxation is one potential cause of ankle clicking which can be painful but can often be addressed through a combination of treatments. It is important to consult a physiotherapist if persistent clicking, weakness, pain, or discomfort in your ankle. With the right diagnosis and treatment, you can get back to enjoying a pain-free and active lifestyle.

If you think you may be suffering from peroneal subluxation and would like to consult one of our physiotherapists, please contact us on 020 7482 3875 or email info@complete-physio.co.uk.